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HomeMy WebLinkAboutApplication and WC ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/yYYY) `f 01/30/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Benson Young&Downs Ins CONTACT Kathy Jones 565A Route 28 (AleNN Fut). (508)432-1256 FAXNe),(508)430-1532 wc.P 0 Box 158 a--milL C• kathyjones@byandd.com Harwich Port MA 02646-0158 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Hartford Fire Insurance Company 19682 INSURED INSURER B:Illinois Union Insurance Company 27960 Raymond C.Roy and RCR Management Inc of London 15792 Salty's INSURER C:Lloyds 540 Main Street,Rte 28 INSURER D: West Yarmouth MA 02673- INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP I TR TYPE OF INSURANCE ween wvn POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS C X COMMERCIAL GENERAL LIABILITY XSZ109424 05/24/2018 05/24/2019 EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED 50,000 CLAIMS-MADE OCCUR PRFMISFS(Fa occurrence) $ ._ J MED EXP(Any one person) 1$ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE '$ 2,000,000 X I POLICY PRO- 1,000,000LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHFR• I$ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Fa accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED J AUTOS ONLY —AUTOS BODILY INJURY(Per accident)i$ HIRED NON-OWNED PROPERTY DAMAGE HAUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS-MADE AGGREGATE I$ _ I DED RETFNTION$ $ A WORKERS COMPENSATION 08WECKH2770 05/18/2018 05/18/2019 X STATUTE FORH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE100,000 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,descdbe under 500,000 .DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Liquor Liability LQRMAF144182104 05/24/2018 05/24/2019 Each Common Cause Limit 500,000 General Aggregate Limit 1,000,000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) j G r-�. ��,� Seasonal Restaurant located at 540 Main Street(Route 28),West Yarmouth,MA 02673. 1a.»��l LED Officers Raymond C.Roy(president)and Stephen J.Roy(clerk)are excluded from workers comp. MAN , 32019 HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION Al 008455 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rte 28 South Yarmouth MA 02664- AUTHORIZED REPRESENTATIVE e,4401`f_ V V aY� I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD